Healthcare Provider Details

I. General information

NPI: 1336705003
Provider Name (Legal Business Name): JACOB GARNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 THE CITY DR S STE 120
ORANGE CA
92868-3352
US

IV. Provider business mailing address

1149 W 190TH ST STE 2200
GARDENA CA
90248-4344
US

V. Phone/Fax

Practice location:
  • Phone: 866-727-8274
  • Fax:
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-51472
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: